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la Chart for Tank Sys* Tightness Test. <br /> PLEASE PRINT - q, <br /> , <br /> 1. OWNER F petty❑ Address <br /> Tank(s)❑ O W`d ctc-V`COD- U Telephone <br /> Name _ Address Rpresentatiw Telephone <br /> 2. OPERATOR N.— Ad&*" Telephone <br /> 3. REASON FOR <br /> TEST vLie <br /> (Explain Fully) <br /> 4. WHO REOUESTED <br /> Come <br /> TEST AND WHEN _ �,p�^ Tkle Comwny w Affiliation Data <br /> ��\t�v ` Address Telepnone <br /> Identify try rection capacity BranW/Stppliot Grade Appro.,Age Steel/Fibergtau <br /> .5. TANK INVOLVED w,(((A"", �4- <br /> Use additional lines <br /> for manifolded tanks <br /> Location cover Fills Vents S�pnones pumps <br /> 6. INSTALLATION r <br /> DATA CQ3vC �j l I <br /> Z <br /> North inside driveway. concrete.Bract Top. Size.Tltefia make.Drop S"ct'on.RMWle. <br /> Rear of station.etc. Earth.etc. tubes.Remote Fills Size.Manifolded Which tanks? Make it known <br /> 7. UNDERGROUND is it,* aiv over in.tank <br /> WATER - Depth to the water table "'. <br /> Tanks to be filled hr. —' 1 Data Arranged by ":j,2D�3 <br /> 8. FILL-UP Marr Telapnp <br /> ARRANGEMENTS Extra product to^top otr and nun tank tester How an0-'no to pro.ld., Consider NO t.a•d. <br /> TwmtnM or other contact <br /> for notice or inquiry <br /> Cot^feM i% k•'b`l~� s�rv, ��: . ,�-�etepnon. <br /> 9. CONTRACTOR, -' <br /> MECHANICS, <br /> any other contractor U U .J•� <br /> invohred <br /> 10. OTHER <br /> INFORMATION <br /> I OR REMARKS <br /> Additional w,l0rrnalion On arty hems aeove.Offielah W others to be advned when lesiknq 4 in progress W rbrrpM.d-vlseas Or oba.rv.n praa.nl during reel,.1c. <br /> l Tests ware Maida ort the above tank syst@m ti teeoydanee wall test Prvicedufes pr..crtb.d to. <br /> i 11. TEST RESULTS d detatted on attached test charts with resorb as folows: <br /> Tank IOenhlicatton Tight Leakage knd4cal d Data Tested <br /> I <br /> t <br /> 12. SENSOR 13.TTla r b ow"th.t tees tank eyeen iml wen tsMed on Ow dabs)atwm Titres kZVS-14 <br /> flas txNerl. by"" <br /> CERTIFICATION �orud r"PfOw`'�'Absocimikm�v++W 3= <br /> TK1>n<tLrr <br /> 1 1—Data <br /> Testing C�Ontrs..leh i mel c.rflflcat/on. �u -� 9. <br /> Addres. <br /> 2 <br /> (:ertlltcetlOn. taertMT <br />